"Health Policy and Programs Evaluative Research for Social Change". An Ibero-American Symposium. Guadalajara, México, November 1-3, 2006Organized by Francisco Mercado-Martínez, PROGIECS, Universidad de Guadalajara, Mexico

Abstract: This is a report of the "Health Policy and Programs Evaluative Research for Social Change" Ibero-American Symposium held
in Guadalajara, Mexico November 1-3, 2006. Attendees represented eight countries, and were associated with NGO's and academic
and health services organizations. The most important themes included in the debates were the meaning of qualitative and
evaluative health research for social change, the challenges of teaching for change, ethical challenges, and possibilities
for making the findings of qualitative research available to different groups or stakeholders (users, policy makers, professionals,
and the population as a whole).

A growing number of Ibero-American academics in a variety of disciplines, as well as members of government and civil organizations,
are showing increasing interest and commitment to the creation of knowledge for promoting social change. Following decades
of isolated qualitative studies in this part of the world, which suffers from considerable social and health inequalities,
this movement has gained increased visibility through projects aimed at applying and disseminating knowledge to several social
groups, whether by involving communities in the design, implementation or evaluation of programs or by incorporating new approaches
to train health resources. Further evidence of this interest is illustrated by groups that have been formed in different settings
and countries to bring about change in the conception and management of knowledge. Accomplishments in this area include alliances
to promote the development of new knowledge and the emergence of strategies to value the experiences and goals of participants
outside academia. [1]

In spite of such interest and practices related to this vision of the production and dissemination of knowledge, consolidation
of these dialogical and transformational projects is still more a question of hopes and aims than of reality. Many of these
efforts have not been systematized or publicized, nor have they been able to break down the separations traditionally dividing
people working in different areas. Above all, there are difficulties in consolidating the epistemological and methodological
bases underlying and guiding day-to-day practices in the health care programs. [2]

A symposium was held in order to discuss this situation and look for alternatives to overcome such obstacles. The conference
"Health Policy and Programs Evaluative Research for Social Change" was held in Guadalajara, Mexico, December 1 to 3, 2006.
It was sponsored by the Universidad de Guadalajara's Qualitative Health Research and Evaluation Program (PROGIECS) with the
support of the Pan-American Health Organization (PAHO/WHO) and the University of San Luis Potosí (UASLP) Faculty of Nursing,
and with additional support from other funding agencies from the participants' countries of origin. [3]

The development of the conference was the result of a series of separate initiatives by Ibero-American academics interested
in qualitative health research and evaluation and, as such, the symposium was the natural outcome of previous collaborative
events. Some of the ongoing debates selected for inclusion in the symposium program were the need to increase cooperation
among Ibero-American scholars, the need to debate current academic production in relation to the critical health thought/movement
in Latin America, as well as the historical separation between academics and those working outside academia. [4]

The initial proposal was for a small group of specialists in qualitative research and others interested to discuss and formulate
proposals based on the following topics: 1) to gather, systematize and disseminate experiences in qualitative research with
a critical perspective; 2) to create and promote alternative forms of health teaching, research, evaluation and dissemination
that include people involved in the field (academics, service providers, civil society, and NGOs); 3) to generate proposals
and strategies to formulate and implement health programs and policy research and evaluation projects; and 4) to create a
network to ensure reaching the proposed goals. [5]

Paradoxically, and despite scarce announcements regarding the meeting, the initiative stimulated enthusiasm from wide and
diverse groups. The list of participants grew to 35 individuals, who came from Brazil, Canada, Colombia, Spain, United States,
Mexico, Puerto Rico and Venezuela. Attendees came from a variety of institutions, both non-governmental and civil society,
as well as universities and government agencies. [6]

The agenda was organized to encourage the participation, both in examining the problems and in proposing solutions and their
implementation. Two panel discussions in which invited speakers from academia, government, civil society and NGOs participated,
served to present an overview of the situation and to point out progress, accomplishments, and difficulties related to evaluation
and research practices, health programs, and social change. [7]

In the first panel discussion, the topic was analyzed from different academic points of view. In the second, the same topic was analyzed, but this time from perspectives outside academia. [8]

Workshops played a central role in the symposium. Coordinated by Dr. Esther WIESENFELD, they involved drawing up a balance
sheet of work accomplished in research and evaluation of health policies and programs and social change, as well as formulating
proposals to tackle the problems identified. Participants were divided into five working groups according to their interests:
1) themes, contexts and key stakeholders in health research; 2) educational outcomes from the academic and community research
for health manpower resources; 3) the impact of academic production on health policies, programs, and social change; 4) dissemination
of academic output among different social groups; and 5) promotion of coalitions between academics, government, and civil
society. [9]

Each of the workshops included representatives from a variety of sectors attending the conference, which helped to stimulate
discussion from different perspectives. The mix of participants highlighted both the advantages and difficulties that can
arise when different viewpoints and proposals for evaluation and research are brought together. [10]

This participatory, dialogical process between participants with different viewpoints, interests, and positions was not free
from tension. In our analysis, we have to acknowledge that the process was not only made of consensus but also of conflict
and polarization of interests between different groups and individuals. This will become clearer later in this report when
we describe the discussion in more detail. Nevertheless, we recognize that these tensions are intrinsic to most forms of social
relations and, as such, should not be seen as a weakness but as a factor contributing to cross-fertilization of ideas and
new developments. [11]

The conclusions reached in each of the five workshops were shared at the end of the first and second days. The results of
discussions and strategies proposed for putting the solutions into practice were presented at the third day. At the close
of the conference, the proposed actions agreed on were distributed for implementation and follow up, and an evaluation was
conducted. Participants indicated a high degree of satisfaction with the work developed in the symposium, as well as a commitment
towards the challenge of putting such ideas into practice. [12]

In the next section, we present some information about PROGIECS, the organization hosting the symposium. This is followed
by a description of key topics debated at the conference, such as the meaning of social change-oriented research, the challenges
of a teaching agenda committed to social transformation, and mechanisms for making health research findings accessible to
society (health care users, policy makers, professionals, and society at large). Unfortunately, some important topics are
not taken into account in this report. [13]

2. The Qualitative Health Research and Evaluation Program (PROGIECS)

This symposium was one of the activities promoted by PROGIECS as a forum for organizing and disseminating qualitative research
and evaluation in Mexico and in Ibero-America. This Program, which is located at the Universidad de Guadalajara in Mexico,
began in 1997, and over the years has become one of the strongest qualitative health evaluation and research initiatives in
Ibero-America. [14]

A fundamental strategy carried out by PROGIECS has been to organize academic events to make qualitative evaluation and research
better known (MERCADO, TEJADA, ALCÁNTARA, MERCADO, FUENTES & TRIGUEROS, in press). In addition to Mexico, similar events have
been organized in Brazil, Colombia, Ecuador, and Spain, and members of the Program have presented their results in other countries,
such as in Canada, United States, United Kingdom, and Sweden. [15]

Around PROGIECS, qualitative research seminars and courses have been organized which have been taught by professors from Mexico,
other Ibero-American and English-speaking countries. Courses have been led by well-known academics in the fields of qualitative
research and/or sociology of health; including among others: Irena MADJAR (Australia), Janice MORSE (Canada), Howard WAITZKIN
(United States), Maria Cecilia MINAYO (Brazil), Jaime BREILH (Ecuador), Jane SPRINGETT (United Kingdom), Juliet CORBIN (United
States), Agnetta ABRAHAMSON (Sweden) and Ciara KIERANS (Ireland). [16]

Some efforts have also been implemented to disseminate the results of qualitative studies conducted by Ibero-American scholars.
A list of books created in collaboration with other Ibero-American authors and a list of publications on qualitative studies
can be found at http://www.cucs.udg.mx/progics/. [17]

PROGIECS has been an International Site of the Institute of Qualitative Methods (IIQM), which is one of the most respected
centers in the world for qualitative health research. Applications to collaborate as co-operating sites have also been received;
for example with the Spanish Qualitative Health Research Network (REDICS). [18]

In addition to activities directed toward academics (researchers, professors, students), PROGIECS members have also worked
to disseminate, by a variety of means, the results of their qualitative studies and methodology to health care workers and
users. One of these initiatives was to publish materials aimed at communicating study results to patients with low literacy
levels (ROBLES, MERCADO & ALCANTARA, 1991). [19]

The coordinators of this organization also have organized conferences in qualitative evaluation and research; these have been
attended by academics from more than 50 different countries. Among the most important of these conferences was the International
Social Medicine Congress (1994) and the IXth International Qualitative Health Research Congress / Ist Ibero-American Qualitative
Health Research Congress (2003). [20]

In summary, since its creation PROGIECS' mission has been to promote the production of health knowledge by means of qualitative
evaluation and research through cooperation between academics and health care stakeholders. In this context, the present symposium
was considered an opportunity to increase the scope of such a project in the Ibero-American context, as well as to build ties
with professionals working outside academia. [21]

3. Qualitative Research and Evaluation and its Relationship to Social Change

Participants of this symposium reached the conclusion that when debating the epistemological premises supporting ways of thinking
and doing qualitative research and evaluation, we should consider the connections between research and social transformation,
justice, and equity. They departed from the principle that not all qualitative researchers share this vision or sense of accountability,
and thus when doing research the assumptions that guide such studies should be made explicit. [22]

As participants of the symposium we reaffirmed the ethical commitment to changing the status quo. We shared the common principle
that "health for all is a right, and health care as a duty of the government," and that governments are responsible for ensuring
social equity and comprehensive health care ("integralidade em saude" in the original Portuguese version; for details see
PINHEIRO & MATTOS, 2006). In this context, evaluation and research projects should help to overcome social inequality. Thus,
researchers should think and act differently from what is proposed by the neoliberal ideology, and should offer a definition
of a "good society" through their work, making explicit their political positions. [23]

As we shared such a vision about health and justice, participants agreed that we should take part in strategies promoting
the redistribution task formerly assumed by the welfare state and to question existing modes of production of subjectivities
that value technology over life, transforming subjects into objects, to finally produce an objective and subjective order
that supports the neoliberal governance in the world (CARVALHO, in press). [24]

In health evaluation and research, accountability to a new social order requires a theoretical and practical position that
confronts the mechanisms of capitalist hegemony, which conflate objective and subjective dimensions of social processes. This
requires consolidation of a transformational praxis in the economic, political and subjective senses, and acknowledges the
need to struggle against

"forms of domination (ethnic, social, and religious); against forms of and exploitation which separate individuals from what
they produce; or against that which ties the individual to himself and submits him to others in this way (struggles against
subjection, against forms of subjectivity and submission)" (FOUCAULT, 1982, p.212). [25]

This position has ethical consequences as it implies a need to visualize the epistemological connections we employ and the
conflicts inherent in them. This, in turn, requires that we be aware of and work on the perspectives that help us the most
to reaffirm our commitment to changing the status quo. Based on these ideas, the group judged certain questions to be of prime
importance: Why produce knowledge? Why evaluate? [26]

Understanding these claims is of fundamental importance for qualitative researchers who aim to contribute to the recognition
of alterity in research—to conceive of the other as an active subject, to prioritize an understanding of the Other's reality
in a communicative dialogue, and which proposes a reflection about critical thinking itself. That is, to some of the symposium
attendees, the quest for the transformation of the status quo involves an exchange in which researchers and participants join
in an intersubjective dialogue where each learns from the other and they participate together in a joint search for collective
projects directed at change in the context of health, illness, and health care. [27]

The richness of this part of the debate in Guadalajara is partially revealed by the issues that follow:

How far does current research go? What concrete acts have been generated? Have participants been effectively empowered? The
key element here is a commitment to social transformation demonstrated by the ability to analyze health practices, and whether
funding to undertake research is being offered to other institutions beyond the academic and scientific communities.

These issues related to the production of knowledge confirm the need for a comprehensive, integrative epistemological basis
for an approach that goes beyond a focus on disease or the health-illness-health care processes to a focus on examining everyday
life. This broadened focus must relate to new theoretical-conceptual elements capable of including emergent health settings
and, as such, a qualitative researcher must fundamentally be an agent of transformation.

The epistemological debate is closely related to ethical issues; hence the need to reaffirm the commitment to social change
in society and in academia itself. The application of ethics throughout a study could be represented by the search for understanding
what kinds of change are necessary if the Other is to have an opportunity for social, economic, or personal development guided
by social justice and new agendas for social change which are relevant for many other social actors .

By "transformation or change," we mean the generation of change processes in the sense of constructing a fairer, more equitable,
and more democratic society. In other words, we ask how social research can serve excluded groups of society whose members
should be considered in the research and evaluation process more than mere "informants."

It is important to keep in mind that research is often designed in response to corporate and academic interests and in the
absence of social interests, desires and needs (for example, improving access to quality services). "Academized" researchers
are not uncommon; they are depoliticized agents who often put themselves at the service of the dominant sector and the status
quo.

New socialization mechanisms are needed to promote dialogue with intersectorial and extra-academic staff. Participatory methodologies
can be very useful in this regard for the possibility in articulating social movements with research. [28]

To summarize, the group agreed that to understand and refine the link between qualitative research and social transformation,
it is necessary to explore the limits and debates surrounding traditional (quantitative) research vis-à-vis qualitative, participatory,
dialogic research. [29]

Other participants, especially those not in academic institutions, reported that they work with research proposals entirely
oriented towards practice, in which the main objective is social change, while epistemological and methodological discussions
had little interest for them. This group has focused on structural change and paid less attention to the different subjectivities
created in perpetuating or changing health policies and practices. They also emphasized the need to create a new epistemology
beyond what is currently considered science. To some academics, this argument constitutes a "return to the past," while others
considered that the production of knowledge is a political act in itself, and its full potential should be appreciated, not
rejected a priori with the argument that it is elitist and exclusionary. [30]

In spite of their quite different viewpoints, participants were able to agree that qualitative, participatory, and dialogical
research and evaluation tend to have social change as a goal. For this reason, it was proposed that the roles of science,
research, and researchers be re-examined through critical reflection and considering which would be the most pertinent approach
to each of the social spaces in which research and evaluation are conducted. [31]

4. Epistemology and Education for Qualitative Research: Challenges and Alternatives

Among the challenges mentioned by participants who teach qualitative inquiry—whether applied to research or to evaluation—was
the recognition of the variety of viewpoints in the field (MERCADO, GASTALDO & CALDERON, 2002). While this reveals the inherent
richness and diversity of qualitative phenomena under study, it also indicates the fragmentation of the field, as expressed
in political and scientific disagreement. This situation shows a weakness in the field that requires rigorous boundaries for
its ongoing task of establishing itself as a scientific tradition, and offers significant challenges to its practitioners
(MERCADO & BOSI, 2006). [32]

Resistance to education grounded on an emergent paradigm remains widespread in science, which is still oriented towards the
so-called "hard science" model. The field of health care in particular is characterized by the positivist tradition and strongly
influenced by quantitative methods. This situation is reflected in the way the tensions between subjective and material issues
are addressed in different degree programs, particularly in medical schools, in Ibero-America and elsewhere. All these elements
have to be taken into account when analyzing the resistance to accepting qualitative methodologies, particularly those directed
at changing social inequalities, for these are the methodologies that challenge the accumulation of social, material, and
cultural privileges. [33]

To counter this state of affairs, it is essential to put up a competent defense of diversity as a principle of excellence
in education to confront those who try to impede an education based on a plurality of paradigms and multiple methodologies
of research and evaluation. The symposium participants reported that they are constantly challenged in academic debate by
researchers with a positivist education. A good command of the epistemological and methodological issues in these dialogues
with the Other is required, in addition to acknowledging that the entire scientific system and its internal economy are based
on quantitative parameters, namely the ubiquitous standard of "academic productivity" (LUZ, 2005), the most recent myth reified
by rewarding mechanisms promoting "the more, the better" mentality. [34]

Superficial, jargon-based or specious arguments about qualitative work are obstacles to strengthening the field. It is vital
that new researchers and stakeholders be educated so that they can practice in such a way as to reclaim the subjective and
the humane for the research field, the landscape of qualitative epistemology. The great variety of existing concepts and poorly
defined "codes" of the field give rise to insufficiently developed and unified concepts (TESCH, 1990), creating an apparent
methodological multiplicity that impedes dialogue among peers and complicates the educational process. Urgently needed countermeasures
include the review of current taxonomies, and building bridges instead of walls between different schools of thought. [35]

The symposium participants also highlighted the need to construct a minimal epistemological baseline within the qualitative
research network that could serve to clarify concepts and add quality to the methodological debate. This does not imply a
homogenization of the inherent diversity and plurality of qualitative research but rather means bringing it into contact with
a process of seeking new syntheses, even if temporary, which would enable a common language understood by all those interested
in qualitative research, including better opportunities for student education. [36]

In summary, the participants of the symposium who work in education called for greater theoretical effort and investment
in the sense of improved systematization of knowledge, definition of the central concepts, acknowledgment of differences,
and identification of juxtapositions and differences within concepts, methods and techniques to expand the dialogical capacity
among different paradigmatic perspectives. [37]

5. To Disseminate, Translate or Exchange Information?

In the context of socially-relevant, dialogical or emancipatory research, academic elitism is often questioned, especially as it relates to the use or application of scientific findings. Speakers and participants representing
civil society from various Ibero-American countries emphasized the need to denounce the general lack of social accountability
by health researchers. Despite the inequalities and injustices in the health care system, they tend to follow a production
market logic with respect to publication, use or application of research results, even for studies that have been funded by
public money and conducted in public institutions. [38]

There was consensus among attendees that while a search for direct application of study findings could be considered reductionist
or even dangerous, it is also true that there is insufficient dissemination of the results of health studies in Ibero-American
countries. For example, the results of studies conducted in universities are often not circulated even in health care institutions
associated with the same university. In other cases, dissemination is asymmetric, with informal networks delivering the results
to a few privileged colleagues. Even today, dissemination is still synonymous with publication in a scientific journal. [39]

In the English-speaking world, the use of research results in practice and in public policy began to be studied in the late
1970s (WEISS, 1979). At first, these studies indicated the need to disseminate results; subsequently, the effectiveness of
different methods of dissemination began to be studied. LANDRY, AMARA, and LAMARI (2001), for example, reported the limited
contribution of traditional approaches to dissemination. In general, they are unidirectional and ineffective in terms of implementation
of results. [40]

In the context of Ibero-American countries, except for a few studies using participatory and participant methodologies, (qualitative)
health research is rarely relevant due to the methods by which the results are disseminated. There is still a gap between
academic research, programs, public policy and health practices. Even health studies conducted within a critical theoretical
framework, such as those that employ emancipatory and dialogical methodologies, seldom include strategies for communicating
the findings to diverse audiences (communities, politicians, professionals), nor are the findings contextualized in relation
to other studies or exchanged with other academic, government or community groups. Part of the problem is due to the existence
of predetermined academic formats for the publication and dissemination of scientific research results. These practices ignore
other dissemination possibilities and show how fragmented the process is in Ibero-America. This happens because researchers
seek forums where research results will be welcomed or will be cited (e.g. high impact factors) but have not worked to create
counter-hegemonic spaces, either at universities or at study sites, to reach those who would benefit or potentially apply
such new knowledge. [41]

The challenge of knowledge translation and exchange, as the process has been called in Canada (CIHR, 2001), requires researchers
to use strategies to generate knowledge that can be shared, whether qualitative or quantitative. In Canada, for instance,
researchers can request funding for collaboration with community groups who participate in the research process or invite
clinicians to participate in the design and formulation of strategies for applying findings. This perspective has already
been in place for decades in methodologies used across Latin American countries; for example in dialogical and participatory
studies that promote connections between different types of knowledge or stakeholders. The Canadian proposal is different
in that it seeks to extend accountability for sharing and co-creating knowledge to both qualitative and quantitative methodological
approaches. In concrete terms, writing articles would become just one of many ways to "publish" (i.e. make public) knowledge
generated by a health study. [42]

Translation of knowledge would combine all steps between the creation of new knowledge and its application to the benefit
of society. These steps include dissemination, communication, administration, utilization, exchange, implementation, synthesis,
consensus-building, and practice protocols, which would vary according to the audience they intend to reach (to government
agencies, to communities, to clinical practice). Some examples of strategies adopted in research projects in the Americas
include meetings with health professionals and policy makers, creating websites, staging plays, and producing photo novels.
In these strategies, however, scientific knowledge, and thus the researcher, may remain as the voice of authority of science,
telling others what needs to be done, but not achieving the paradigmatic change referred to in the previous section. [43]

If these Canadian experiences would be taken into account in Ibero-America, the customary concept of dissemination or translation
could be questioned. In Canada, translating knowledge is usually seen as "exchange, synthesis and ethically-sound application
of knowledge—within a complex system of interactions among researchers and users—to accelerate the capture of the benefits
of research for [people] through improved health, more effective services and products, and a strengthened health care system"
(CIHR, 2001). Some participatory and dialogical studies in Latin America have tended to involve a "complex system of interactions
between researchers and users" and to make dialogue the methodology for producing hybrid knowledge that could generate local
answers for pervasive social problems. Some examples of this approach can be observed in social medicine, collective health,
and participatory action research studies in this region. [44]

To achieve this ethical ideal of inclusion means tackling personal and institutional barriers in every country and, more importantly,
it implies a change in the nature of research which currently involves the process of generating, but not sharing knowledge.
Researchers will have to acquire new skills, including planning projects with timelines that allow them and participants to
co-produce socially-relevant knowledge, or for translation and exchange with practice settings; integrating findings with
those of other studies in order to be able to propose applications that go beyond the specifics of any one study; involving
community stakeholders and program administrators in evaluating studies so that the results might be used on a larger scale
and different contexts. [45]

In spite of similarities between the Canadian proposal and the Latin American tradition for participatory action research
(FALS-BORDA, 2003), the logic of traditional science still prevails in both regions. Barriers include, for example, lack of
funding for including these initiatives as an integral part of research projects, and the fact that productivity is interpreted
as large studies with the shortest possible duration. The dominant scientific paradigm of neutrality and generalization
makes it more difficult to understand that local knowledge and changes also contain contextualized general knowledge. The
search for knowledge translation and exchange is an alternative to the linearity of many scientific projects, which fail to
appreciate the complexity of social contexts where this knowledge should be used, and as a result produce knowledge that is
not applicable or has little relevance. [46]

The need to create forums for democratizing health knowledge is thus evident: places where this knowledge can be available
to anyone who needs it. There is also a need to establish validity criteria that will allow others to critique and use research
results and to have reference points that enable their own reality to be changed. [47]

Considering these points together, it is necessary to consider the political and economic interests that are involved in the
formal dissemination of research results, which often limit access to information. These include dissemination technology
and resources not available to all or which due to cultural or educational differences cannot be used by all even if they
are available. In other words, it is important not only to recognize the importance of translating and exchanging results,
but also of employing alternative means, both intersectoral and intercultural, to reach diverse audiences. [48]

6. Operational Routes and Strategies

As qualitative researchers, we aspire to attain a complex vision of reality, attempting to see plurality, similarity and difference.
From the scenario described above, we recognized the need to develop strategies to bring us closer as a diverse group of current
and potential collaborators aiming at creating new social practices in the health arena. Given this, it seemed appropriate
to work as a network that would express the richness and diversity of approaches, perspectives, and participants present at
the symposium. The four routes that follow were the ones perceived as most relevant by the participants. [49]

6.1 Building a qualitative health research and evaluation network

For the participants of the symposium it is essential to increase our knowledge of the Ibero-American qualitative health landscape,
including knowing who are the researchers and other co-workers in the Ibero-American countries, their strengths and weakness,
their fields of study, their institutions, their political and ideological motivations, and the projects they are currently
developing, in order to bring them closer into a network. Previous Ibero-American efforts have been made in relation to publications
(MERCADO, GASTALDO & CALDERON, 2003) as well as in FQS (edited as vol. 7, issue 4 by CISNEROS, DOMÍNGUEZ, FAUX, KÖLBL & PACKER, 2006) and the Revista Española de Salud Pública (vol. 76, issue 5, 2002). In constructing the map of this network, it is also important to know what health means to each
stakeholder and group, how health work is organized in different countries or regions, how researchers relate to practice
settings and how they understand the role of participants, among others. This means we are proposing a collaborative, contextualized
task force among those who can forge alliances to produce enhanced research projects to achieve greater impact on different
settings. In addition, as part of the process, formalizing alliances by institutionalizing them could be considered. To do
so, it is suggested that the potential of modern technology be explored (e.g. distance education and virtual collaboration
networks) as they can be of great help for teaching qualitative evaluation and research for social change. [50]

6.2 External action

Venues for action would include joint work with communities and groups in their relationships with health services, which
constitute a vast field to be explored in Ibero-America (e.g. hospitals, health centers, health care teams, tertiary care
organizations, social health movements), as well as the area of education for health human resources. It is worth noting the
capacity of interchange of this group, being wise to explore our existing scientific capital and established interfaces, especially
those experiences stemming from the Latin American social medicine/collective health tradition (NUNES, 1989). [51]

Among other potential objects of qualitative research or evaluation, the group also highlighted other topics emerging from
everyday health care demands. These included planning and implementation processes in health units, caring for caregivers
and health professionals, social participation in health care, students' experiences in health services, humanization of health
care practices, and reorienting health care services and evaluation. [52]

6.3 Training the trainers

Many symposium participants commented on the gap between teaching and research, which stems from a lack of policy and funds
in Ibero-America for education in qualitative evaluation and research. Therefore, attention must be focused not only on increasing
the number of people involved in qualitative evaluation and research but also on the quality of their research production.
[53]

It is suggested that education in qualitative methods in Ibero-America be part of an agenda for reclaiming the training and
evaluation processes in a variety of socio-cultural contexts. This would require academic support in more than one sense;
reinforcing resistance to external pressures dictating the educational agenda of health workers and designing and promoting
education that sensitizes people to the need to participate in social change. It is recommended that this training process
include both a basic and an advanced element. Advanced training (educating the teachers) is essential, given the scarcity
and increasing demand for academic staff to teach evaluation and research. The number and qualifications of professors and
researchers in this area urgently needs to be increased. In addition, it is essential that qualitative inquiry be extended
in such a way as to respond to the growing demand for studies and evaluations. These requests are often responded to by
researchers who do not have the proper qualification, which leads to methodological errors and negative effects on the entire
field. [54]

The participants' opinion was that a training and exchange process within the symposium group should also be promoted; in
other words, a dialogue within the network itself which would be carried out collectively. Distance learning, experiential
learning, and adult education are valuable methodologies in this regard. [55]

Another proposal made was the incorporation of gender perspectives into education in evaluation and research. The feminization
of these processes has increased significantly in recent years in Ibero-America. [56]

Lastly, a question was raised but not answered: How to increase the instances in which qualitative research and evaluation are conducted without losing quality? [57]

6.4 Collaboration projects

Symposium attendees acknowledged the work carried out through collaboration between academics in Ibero-America in recent
years. They proposed that this experience be leveraged by promoting the development of qualitative-participatory-dialogical-multisite
studies. Among the topics that could be of common interest to Ibero-American academics and health professionals are comparative
studies of health programs, qualitative studies on human health resources education, and studies of the production, distribution,
and consumption of medication in health care services. [58]

As stated previously, another priority topic is that of promoting links between stakeholders. The Ibero-American Qualitative
Health Research Conference, as well as the Ibero-American Qualitative Research Conference, can play a central role in strengthening
connections and links for cooperation. Participants agreed to promote and support efforts to this end. [59]

Weiss, Carol (1979). The many meanings of research utilization. Public Administration Review, 39(5), 426-431.

Authors

Francisco MERCADO-MARTÍNEZ, MD, PhD, professor at the University of Guadalajara, México; director of the Qualitative Health Research and Evaluation
Program (PROGIECS); author of more than one hundred publications. Research interests: chronic illness and inequalities, qualitative
health research and evaluation and critical research approaches.

Denise GASTALDO, BScN, MA, PhD, associate professor and associate dean at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto,
Canada. She has developed research projects in Canada, Spain, and Brazil in the areas of health promotion, migration, and
social inclusion.

Maria Lúcia M. BOSI, PhD, associate professor and coordinator of the Public Health Master and Doctoral Programs at the Federal University of
Ceara, Brasil; PhD in Public Health. She is a researcher of the Consejo Nacional de Desenvolvimiento Científico y Tecnológico,
CNPq/Brasil. Her areas of interest: qualitative research and evaluation of primary health care. She collaborates with over
15 journals.

Sergio Resende CARVALHO, PhD, professor at the State University of Campinas (UNICAMP), São Paolo, Brazil. Areas of interest: subjectivity, power
and management in primary health care. He coordinates a project on qualitative evaluation of labor management and training
of health professionals in primary health care. He collaborates with numerous journals.

Esther WIESENFELD, PhD, professor at the Universidad Central de Venezuela (UCV); PhD in Social Psychology; author of over 50 articles. She
has been Head of the Departamento de Investigaciones Aplicadas del Instituto de Psicología de la UCV.

Irma Xóchitl FUENTES-URIBE, BM, MBA, professor at the University of Guadalajara Economic and Administrative Sciences Center. She is also research assistant
at the University of Guadalajara Health Sciences Center.